Inside Health

By ANDREW POLLACK

Published: March 11, 2006

Joseph A. Brocato's weekly self-injections of a drug to treat hepatitis C left him so feverish and fatigued, he said, he often thought of quitting. He didn't, thanks to a nurse who urged him by phone to stay the course.

The nurse, Colleen Dinsdale, did not work for Mr. Brocato's doctor. Rather, Ms. Dinsdale was paid by the drug's maker, Roche, and its distributor, McKesson. Each month that Mr. Brocato took the drug, Pegasys, and its companion pill, ribavirin, meant $3,000 in sales -- most of it paid by his insurance company. His share was a $50 co-payment.

The take-your-medicine program is part of a sales and marketing strategy that is gaining urgency for drug makers experiencing slowing sales. As it turns out, the industry leaves billions of dollars on the table -- or the pharmacy shelves -- annually because people do not take their drugs as often or as long as prescribed.

And so the hand-holding with patients like Mr. Brocato, who recently completed his yearlong course of therapy. ''They don't ever let a week go by that they don't contact you, not just to say you are coming up on a refill of your drug but just to say, 'How are you feeling?' '' said Mr. Brocato, a 57-year-old auto parts deliverer who lives in Dundalk, Md. He said he called Ms. Dinsdale so much that he programmed her number into his cellphone.

Stimulating sales this way is the focus of other industry initiatives, including television advertisements like one by AstraZeneca in which a doctor asks a series of patients if they are taking their Toprol-XL hypertension pills daily. ''You can't forget,'' the doctor gently scolds. ''High blood pressure can make your heart work harder than it should, every day.''

Lending credence to such efforts are many studies showing that failure to take medicines as prescribed can cause patients to develop more serious and costly complications later. So as industry tactics like wining and dining doctors draw scrutiny, spurring people to take their pills is a less controversial way to increase sales, one that the industry says is in the best interests of patients and insurers.

Still, the efforts are not without detractors. Some medical experts worry about consumers' privacy or the possibility of undermining doctor-patient relations. There are also questions about the industry's motives.

''They're about brand loyalty and not about public health,'' said Dr. Jerry Avorn, a professor at Harvard Medical School and the author of ''Powerful Medicines,'' a book critical of pharmaceutical marketing and regulation.

Dr. Avorn nevertheless said that low patient compliance with prescriptions was a big problem for the industry and public health. ''I'm often surprised to hear drug companies worry about increasing their market share from 7 percent to 9 percent for a particular disease, when the 500-pound gorilla issue is that half the people who were prescribed those drugs aren't taking anything,'' he said. ''A ton of money is wasted on paying for drugs which people use so irregularly that they get no clinical benefit.''

The World Health Organization, in a report in 2003, called noncompliance a ''worldwide problem of striking magnitude.'' It estimated that in developed nations, half of patients did not take medicines for chronic diseases in the prescribed manner.

Insurance companies have their own programs to get customers to take their medicine. But it is the drug companies that feel the most direct impact when patients fail to finish or renew prescriptions.

''We talk about this in terms of the leaky bucket,'' Anne M. Faul, director of pharmacy strategy and analysis at GlaxoSmithKline, said on a recent Webcast organized by Frost & Sullivan, a consulting firm, and sponsored by McKesson.

GlaxoSmithKline, which makes the diabetes drug Avandia, is offering to pay for employer groups in 10 cities to replicate an experiment that started in 1997 in Asheville, N.C.

In that test, Asheville municipal employees with diabetes were encouraged to take treatments for their disease, through efforts by pharmacists and diabetes educators and by the waiver of co-payments. As a result, the patients' control of their blood sugar improved and the city's overall medical costs fell. Spending on drugs alone, however, increased.

Research finds various reasons that people do not take their medicines. Forgetfulness accounts for about one in four cases, according to a survey of 10,000 people in 2002 by Harris Interactive and the Boston Consulting Group. Another reason is that patients may feel no urgency about taking daily pills for conditions like osteoporosis and high cholesterol, in which drugs do not relieve any immediate symptoms but reduce the risk of future problems.

Other reasons, cited by the survey and other specialists, are ones the drug industry's inducements cannot necessarily resolve -- like complaints that the drugs cost too much or do not work or cause unpleasant side effects.

Kay Wissmann of Chicago said she stopped taking tamoxifen, intended to prevent a recurrence of breast cancer, because it made her feel terrible and exhausted. ''That's one of the things oncologists don't realize, because they've never taken the medications themselves,'' she said.

Even though she had a relapse of cancer, she said that not taking the drug was the right decision.